Dental teaching model

This position paper examines historical changes and current trends in dental education and practice and attempts to predict the future. Dental education and practice, especially in the wake of the COVID-19 pandemic, is at a crossroads. The future is shaped by four fundamental forces: the rising cost of education, the deprofessionalization of dental care, the corporatization of dental care, and technological advances. Dental education can include personalized, competency-based, asynchronous, hybrid, face-to-face and virtual learning, providing students with multiple starting and ending points. Likewise, dental offices will be hybrid, with both in-person and virtual patient care available. Artificial intelligence will increase the efficiency of diagnosis, treatment and office management.
“Dental education and practice are at a crossroads” is often mentioned in our professional discussions. This statement makes more sense now than it did in 1995 (1). It is important to recognize the relationship between dental education and practice as they influence each other. Moreover, a comprehensive understanding of the current situation requires consideration of the long-term trends shaping these areas.
The origins of dental education can be traced to an informal apprenticeship-based model in which the profession was passed on from one practitioner to another. With the opening of the first dental school in Baltimore in 1840, this tradition evolved into a more formal school-based system. Dental education has recently undergone further significant changes from site-based education to distributed education using multiple clinical sites and hybrid models encompassing both virtual and in-person interactions, compounded by the challenges posed by the evolving COVID-19 pandemic.
In the 183 years since the founding of the Baltimore School of Dental Medicine, the first dental school in the United States, the landscape of dental education has changed dramatically. Dental education has shifted from private, for-profit, independent professional schools to university-based, not-for-profit health education institutions. The number of dental schools in the United States peaked in 1900 at 57, fell to 38 around 1930 after the publication of the Gies report (2), and then recovered to 60 in the 1970s. After closing and then reopening in the 1980s, the number of schools now stands at 72, with at least seven more schools planned to open in the next 2-3 years (3).
At the same time, the components of dental education are becoming increasingly complex. Initially, one student, one teacher, one patient and one physical space will be sufficient. However, over the past 183 years, courses, clinics, preclinical, classroom, and simulation environments have grown and diversified. Faculty quality and diversity, formal testing procedures, and multi-tiered regulatory and compliance components are added to enhance the overall educational experience.
The cost of dental education has also changed dramatically, increasing the burden of student debt. In the early stages, formal training from a dental practitioner is required, and after 1–2 years, students can work independently. Regulation of the practice of dentistry in the United States was initially sporadic, with Alabama becoming the first state to regulate it in 1841. By 1910, state licensing became mandatory in all states. In the mid-19th century, tuition cost about $100, a huge amount of money. With the opening of the first dental school in 1840, tuition fees of $100 to $200 became common. Over 140 years (1880 to 2020), tuition at a typical private dental school in the United States has increased 555 times, outpacing inflation by 25 times (4). In 2023, the average debt of recent dental school graduates will be $280,700 (5).
The multifaceted history of dental practice unfolds across a variety of treatments, each occurring at different points in its broad timeline (Figure 1). These levels include extraction dentistry, which is the earliest form of treatment; restorative and alternative dentistry, which began in 1728 during the era of Pierre Fauchard, considered by many to be the “father of dentistry”, based on preventive dentistry, which began in 1945. Diagnostics; Dentistry-based dentistry emerged in the 1960s with the development of water fluoridation technology, when saliva, oral fluids and tissues became the key to diagnosing local and systemic diseases. A revolutionary treatment is currently being developed that provides oral health based on regeneration and manipulation of the microbiome, paving the way for the future of dentistry. The key question is what will be the proportion of these different forms of dental practice in the future.
Figure 1. Historical stages of dentistry. Excerpted from The Illustrated Encyclopedia of Dental History by Andrew Spielman. https://historyofdentistryandmedicine.com/a-timeline-of-the-history-of-dentistry/. Reprinted with permission.
This shift has transformed the practice of dentistry from a purely mechanical focus (extraction, replacement and restorative dentistry) to one dominated by chemical and biological aspects (preventive dentistry) and is now moving into the field of molecular oral health (regenerative dentistry). ). and based on microbiome manipulations).
Another important evolution occurred in the history of dental practice: from a general approach to dental treatment (throughout most of its history) to a more specialized paradigm (beginning around 1920) marked by the uniqueness of the dental profession. Dentistry is moving towards personalized forms of care that reflect a sensitive and personalized approach to oral health.
At the same time, early forms of dentistry moved from mobile dentists providing services in different locations (most dentistries before the 19th century) to a predominantly stationary model of dental care (19th century to present). However, in the early 2000s, with the advent of teledentistry, a hybrid form of dental care delivery emerged that combined traditional face-to-face services with remote digital interactions, thereby changing the way dental care is delivered.
At the same time, the dental practice landscape also underwent a transformation, from private dental practice (throughout much of the 19th and 20th centuries) to group practice owned by one or more dentists (beginning in the 1970s). transition to a dental company owned organization (DSO) (mostly in the last 20 years). This remarkable recent trend, popular primarily among young graduates, highlights the changing dynamics of dental care provider structures and the trend toward corporatization of dental practice similar to medical practice decades ago. The ownership structure of individual dental practices has changed significantly over the past 16 years. Among those aged 65 years and older, personal ownership of a dental practice decreased slightly by 1%, while among those under 30 years of age the decline was more significant, reaching 15% (6). A survey of the Class of 2023 found that 34% of graduates planning to enter private practice after graduation were considering joining a DSO, a number that has doubled in just five years (5). This shift highlights generational differences in the ownership models favored by younger dental professionals due to the higher risks, administrative burdens and costs of running an independent practice. The corporatization of dental practice also challenges the traditional autonomy of dental practitioners.
Dental regulation and oversight in the United States has undergone a transformational evolution. During the colonial period, oversight was virtually non-existent. By 1923, this structure had grown into four institutions (Fig. 2). Over the next 100 years, the regulatory environment expanded significantly, and oversight powers expanded to at least 45 government, state, and local agencies, commissions, and executive departments. This progress reflects a significant increase in the complexity and diversity of the regulatory infrastructure and administrative burden of dental practice and education in the United States.
Four powerful forces are challenging traditional dental education and practice. These include the cost of education, technological advances such as virtual and augmented reality, artificial intelligence, teledentistry, “non-invasive” dental treatment, that is, non-invasive treatment performed by a number of mid-level providers and even the public, and the corporatization of dental practices.
The first affects education, the third and fourth affect practice, and the second affects both. These areas are briefly discussed below and open the debate about where dental education and practice can be directed.
While we have briefly discussed current education costs, it is worth taking a deeper look at the need to address future costs that will force schools to make strategic adjustments. In particular, there will be an increasing need to reduce operating costs and tuition fees through the use of more cost-effective tools. The most promising path to increased efficiency is through technological advances that can significantly reduce the overall cost of providing education.
The cost of dental school is primarily related to faculty salaries, administrative staff, and operating expenses, including clinic-related expenses. Recent experiences with the COVID-19 pandemic have demonstrated the ability to continue high-quality dental education remotely even when physical dental offices are closed. This makes it possible to deliver many courses digitally, thereby reducing the need for teachers to use shared resources. This shift could pave the way for multiple dental institutions to share curriculum and faculty remotely in the future, eliminating the need for ownership and potentially leading to significant reductions in administrative and faculty salary costs.
Additionally, the integration of virtual reality (VR) and augmented reality (AR) simulations into asynchronous preclinical education is a transformative step. This innovation could standardize feedback and achievement of individual abilities at different speeds, reminiscent of airline pilot training programs that use simulators to develop skills. This approach has the potential to revolutionize preclinical dental education by creating a more efficient and standardized learning environment.
VR is currently used in various medical and dental schools. Here are some examples. HoloAnatomy, developed by Case Western Reserve University, provides augmented reality capabilities that allow medical students to interact with 3D holographic anatomical models for in-depth learning. Another program, TouchSurgery, offers a VR surgery simulator that allows healthcare professionals to practice various surgical procedures in a realistic 3D environment. Osso VR focuses on surgical training and provides a virtual environment in which healthcare professionals can practice surgery and improve their skills through realistic simulation. Finally, Virti offers VR and AR simulations for emergency response training. Healthcare professionals can practice responding to medical emergencies in real-life scenarios.
Several examples of the use of AI include AI virtual patient simulations, which allow dental students to practice various procedures in a realistic, safe virtual environment (7). These simulations may include diagnostic test scenarios, treatment plans, and hands-on procedures.
a) Adaptive learning platforms use artificial intelligence algorithms to customize educational content based on the progress, learning style and performance of individual students. These platforms can provide personalized tests, interactive modules, and targeted resources to meet specific learning needs.
b) Artificial intelligence applications can analyze diagnostic images, such as x-rays or intraoral films, and provide immediate feedback on students’ interpretation skills. This helps students improve their ability to diagnose various oral diseases.
c) Virtual and augmented reality applications powered by artificial intelligence create immersive learning experiences. Students can study detailed 3D models of dental anatomy, interact with virtual patients, and practice surgical procedures in a simulated clinical environment.
d) Artificial intelligence supports distance learning by providing distance education platforms. Students can participate in virtual lectures, webinars and collaborative discussions. AI features may include automatic transcription, Q&A chatbots, and student engagement analytics.
e) Technology companies are partnering with healthcare providers and universities to provide educational content through their platforms. This content may include articles, videos, and interactive resources covering a variety of dental and medical topics. For example, Coursera offers Frontiers in Dental Medicine and Dentistry from the University of Pennsylvania, Dentistry 101 from the University of Michigan, and Dental Materials from the University of Hong Kong. MIT OpenCourseWare provides free access to Neuroscience courses and more.
f) Finally, Khan Academy offers a number of free dental courses covering topics such as oral anatomy, dental materials, and basic science courses traditionally offered by medical and dental schools.
Another implication is the provision of virtual, non-invasive dental care. Teledentistry has become an alternative to regular in-person dental care.
As many preventative dental interventions become less invasive, there is less need for dentists to perform all the steps currently offered in dental offices. Other healthcare providers such as dental hygienists, advanced practice dental hygienists, dental therapists, dental nurses and even teachers, doctors, nurses and parents will be able to provide some non-invasive care, making dentistry non-invasive. When preventive dentistry (fluoride, teeth whiteners, denture adhesives, oral protectants, and pain medications) hits over-the-counter store shelves, some services may be provided by mid-level providers and even non-professionals.
Ultimately, it is only a matter of time before secularization and teledentistry come together to provide non-invasive dental care anytime, anywhere.
Another factor in dental education and dental care is the involvement of big tech and the use of artificial intelligence in dental education and care. Large technology companies often partner with healthcare organizations, nonprofits, and educational institutions to promote medical education initiatives. Several major technology companies are increasingly interested in using their platforms and technologies to provide information, resources and educational content related to oral and general health. Examples include:
a) Technology companies develop and promote health-related apps and platforms that provide educational content on various health topics. These apps can provide fitness nutrition information, track water intake, remind users to brush their teeth, provide general advice on maintaining good oral hygiene, and provide virtual dental consultations or oral health tips. In a 2022 Medline study, Thurzo et al. (8) found that dental studies related to artificial intelligence included radiology 26.36%, orthodontics 18.31%, general volume 17.10%, prosthodontics 12.09%, surgery 11.87%, and education 5.63 %.
b) Use artificial intelligence to develop health assistants that provide personalized health information and recommendations. Artificial intelligence applications developed by technology companies show promise for dental image analysis and diagnosis. For example, artificial intelligence algorithms help analyze dental radiographs such as X-rays and CBCT scans to identify conditions such as tooth decay, periodontal disease and abnormalities. They also improve the clarity of dental images, helping dentists more efficiently visualize details and make accurate diagnoses.
c) Similarly, artificial intelligence algorithms evaluate clinical data, including periodontal probing depth, gingival inflammation (9) and other relevant factors, to predict and diagnose periodontal disease. The AI-powered risk assessment model analyzes patient data, including medical history, lifestyle factors and clinical outcomes, to predict the risk of developing specific oral diseases. Currently, artificial intelligence models require further development to diagnose periodontal bone loss (10).
d) Another potential is the use of artificial intelligence to develop treatment plans in orthodontics and orthognathic surgery (11) to track tooth movement and reconstruct 3D digital models (12) to help predict tooth movement and optimize orthodontic planning of tooth movement. surgical intervention (13).
e) Artificial intelligence systems analyze images obtained using intraoral cameras or other imaging devices to identify abnormalities or potential signs of oral cancer (14). Artificial intelligence algorithms are trained to identify and classify oral lesions, including ulcers, white or red plaques, and malignant lesions (14, 15). Artificial intelligence is great at making diagnoses, but when it comes to making surgical decisions, caution is required.
f) In pediatric dentistry, artificial intelligence is used to detect carious lesions, improve the accuracy and efficiency of diagnostic imaging, improve treatment esthetics, simulate outcomes, predict oral diseases, and promote health (16, 17).
g) Artificial intelligence is used to manage practice with virtual assistants and AI-powered chatbots to help schedule appointments and answer basic patient questions. AI-powered speech recognition technology allows dentists to dictate clinical notes, reducing recording time. Likewise, AI is facilitating teledentistry by enabling remote consultations, allowing dentists to assess patients and make recommendations without the need for an in-person visit.
The transformation of dental education involves a transition from a centralized model to a more decentralized and technological approach. The fragmentation of dental education is evident as it is recognized that some aspects of learning can be effectively delivered asynchronously online using simulations and artificial intelligence-based feedback. This departure from the traditional model challenges the need to provide all education simultaneously under one roof.
Inspired by the example of airline pilot training, future dental education content could be outsourced to specialized technology centers, similar to how Prometric sites play in testing. This reorganization means that students will no longer have to begin and end their educational journey with a fixed set of “classmates.” Instead, a customized schedule will be developed based on the achievement of specific competencies. These competencies will be patient-centered rather than student-centered and will be time-based, as they are now.
Although clinical education still requires practical experience, a rigid cohort structure is no longer necessary. Students may engage in these practical aspects at different times, in multiple clinical settings, and in different groups. Virtual education will dominate didactic and preclinical components, emphasizing flexibility through asynchronous learning. In contrast, the clinical component will have a hybrid format, combining in-person experiences with virtual elements.
The decentralized, hybrid, synchronous and asynchronous nature of this personalized education model brings significant economic benefits to students. At the same time, it helps reduce the traditional roles of dental school faculty, staff, and administrators and re-evaluate the physical space required. Thus, the future of dental education will be based on a dynamic and efficient model that adapts to the changing needs of students and industry.
The proposed model is only one approach to achieving cost-effectiveness in dental education; a comprehensive analysis should include the total cost and length of college and dental education. Reducing the duration of universal education may reduce potential costs. For example, the current practice of admitting students after the first year of college for a limited portion of students may contribute to this decline. In addition, the length of dental education could be shortened by making some basic science courses mandatory. Another way to increase efficiency, save time, and reduce costs is to integrate DDS with graduate education.
Over the past decade, the healthcare sector has seen a surge in mergers and acquisitions in health insurance, medical services, chain stores and pharmacies. This trend has led to the emergence of “microclinics,” which provide comprehensive preventive care in multiple locations. Major retailers such as Walmart and CVS have incorporated dentistry into these clinics, hiring professionals to provide simple surgical and preventative care, challenging traditional reimbursement models.
Integrating dental services into the broader health care system can revolutionize access to health care by providing comprehensive health care services, including general preventative care, vaccinations, prescription medications, and oral health care, at a lower cost. Streamlined operations extend to billing processes and the integration of patient information among healthcare providers.
These transformative clinics are emphasizing prevention and holistic health care, especially as insurance reimbursement shifts to outcome-based assessments, changing the dynamics of health care and promoting a holistic approach to patient well-being. At the same time, the corporatization of dental care and the growth of small practices may turn dentists into employees rather than independent practice owners.
With the dramatic increase in the elderly population, one of the major challenges facing clinical dentistry is about to arise. If you extrapolate from a base population of 57 million Americans age 65 and older in 2022, the number of Americans in the same age group is expected to reach 80 million by 2050, according to U.S. Census Bureau projections. This is equivalent to an increase in the proportion of older adults among 5% of the total US population (18). As demographics change, a corresponding increase in the absolute number of oral lesions in older adults is expected. This means that there is a growing need for dental services that specifically address the unique oral health needs of older adults (19, 20).
Anticipating technological advances, dentists of the future are expected to offer hybrid treatment systems that integrate remote services and a combination of telemedicine and face-to-face communication. The changing treatment landscape highlights a shift toward biological, molecular, and personalized care (Figure 1). This shift requires healthcare professionals to expand their biological knowledge and critically engage with scientific advances.
This transformative environment promises to facilitate the development of specific dental specialties, with endodontists, periodontists, oral pathologists, dental practitioners and oral surgeons leading the way in the adoption of regenerative dentistry. This evolution is consistent with a broader trend toward more sophisticated and personalized approaches to oral care.
No one has a crystal ball to predict the future. However, pressures from educational costs, corporatization of practice, and technological advances will increase in the coming decades, providing cheaper and more effective alternatives to the current model of dental education. At the same time, informality and technological advances in dentistry will provide more efficient, cost-effective and broader opportunities for prevention and care.
The original materials presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.